Unnecessary EKGs – The Heart of the Matter

Sharon Begley’s cover story in the August 22nd edition of Newsweek begins with an anecdote about my own refusal for an EKG: “Dr. Stephen Smith…tells his doctor not to order…an annual electrocardiogram to screen for heart abnormalities….” To clarify, I didn’t object the first time an EKG was ordered by my primary care doctor, but when he suggested ordering the test again the following year, I declined.

My first EKG was normal and I had no symptoms or illnesses that would justify obtaining another one.

Why do doctors persist in doing things for which there is no evidence supporting the practice? The answer that jumps out is “financial incentive.” I think that’s correct, but in a more subtle way than most people might assume. Let me explain:

I first went into private practice with an older physician whose ancient EKG machine didn’t work reliably. I finally convinced him to buy a new one, which was rather expensive. After a few months, I noticed that I had been ordering EKGs much more frequently than I had previously. Just about any reason had become sufficient for me to order an EKG, including the notorious “annual EKG.” I realized that my new criteria for ordering an EKG was subconsciously motivated by my desire to show my partner that his investment would pay off. I personally didn’t make a penny extra by ordering more EKGs since I was paid exclusively on a salary basis. But the financial interests of the practice clearly had affected my clinical decision-making. Once I confronted this reality, I changed my criteria for ordering EKGs back to what it had previously been.

When the National Physicians Alliance field-tested items for the “Top 5″ list in the Good Stewardship project, one internist argued against the item concerning EKGs. His argument was that occasionally they did reveal unanticipated pathology that he could do something about, though admittedly this was uncommon. When pressed, he did agree that doing one every year on healthy, low-risk patients whose previous EKG was normal was unnecessary.

I hope that by discussing the issue with this thoughtful internist, he might reflect on his own practices and modify them. I have faith that most physicians have enough professional pride and integrity to do the right thing once they actually think about it.

Stephen R. Smith, MD, MPH is professor emeritus of family medicine at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. He retired in 2007 as associate dean, a post he had held for 25 years. During his tenure as associate dean, Dr. Smith earned an international reputation for innovation in medical education. He was the architect of the competency-based curriculum at Brown that has been replicated at many medical schools around the world.

Since his “retirement,” Dr. Smith has been working part-time in the community health center in his hometown of New London, Connecticut, and organizing physicians in Connecticut for the National Physicians Alliance (NPA). He also served as the principal investigator of an NPA project funded by the ABIM Foundation to promote good stewardship in primary care. He earned his medical degree from Boston University School of Medicine in 1972 and his master of public health degree from the University of Rochester in 1977.

2 Comments to “Unnecessary EKGs – The Heart of the Matter”

That is an excellent question – As a Canadian Doctor, I don’t think that we are as sensitive to malpractice claims as our colleagues in the south do. (Personally I’d rather be sued for doing the right thing than avoid being sued by doing the wrong thing – but it is easy for me to say as the chance of being sued is actually very low).
The issue of unnecessary tests is complex and includes:
1) the textbooks that we use to teach our students were written in the US by people under significant medico-legal pressure.
2) We live in a culture of ‘more is better’ and as a service industry, we think we are giving our patients a better ‘deal’ if we do more stuff.
3) Doctors often don’t understand how tests work and which tests suit which circumstance – it is often easier to order test than to think.
4) Patients often believe in tests as some kind of exact science with a binary outcome (you are sick, or you are not, and there is a test that will tell you). This is clearly very wrong.

I wonder about how many unnecessary tests are performed for financial incentive compared to how many unnecessary tests are performed with the thought of preventing a medical malpractice suit. Do doctors admit to that?